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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 3 - Procedures

Forceps delivery

  • Review for conditions:

- vertex presentation or face presentation with chin-anterior or entrapped after-coming head in breech delivery;

- cervix fully dilated;

- head at +2 or +3 station or 0/5 palpable.

At a minimum, the sagittal suture should be in the midline and straight, guaranteeing an occiput anterior or occiput posterior position. 

  • Provide emotional support and encouragement. If necessary, use a pudendal block.

  • Assemble the forceps before application. Ensure that the parts fit together and lock well.

  • Lubricate the blades of the forceps.

  • Wearing high-level disinfected gloves, insert two fingers of the right hand into the vagina on the side of the fetal head. Slide the left blade gently between the head and fingers to rest on the side of the head (Fig P-10).

A biparietal, bimalar application is the only safe application. 


Figure P-10

Applying the left blade of the forceps


  • Repeat the same manoeuvre on the other side, using the left hand and the right blade of the forceps (Fig P-11).

Figure P-11

Applying the right blade of the forceps


  • Depress the handles and lock the forceps. 

  • Difficulty in locking usually indicates that the application is incorrect. In this case, remove the blades and recheck the position of the head. Reapply only if rotation is confirmed. 

  • After locking, apply steady traction inferiorly and posteriorly with each contraction (Fig P-12).

Figure P-12

Locking and applying traction


  • Between contractions check:

- fetal heart rate;

- application of forceps.

  • When the head crowns, make an adequate episiotomy.

  • Lift the head slowly out of the vagina between contractions.

The head should descend with each pull. Only two or three pulls should be necessary.


  • Forceps failed if:

- fetal head does not advance with each pull;

- fetus is undelivered after three pulls with no descent or after 30 minutes.

• Every application should be considered a trial of forceps. Do not persist if there is no descent with every pull.

• If forceps delivery fails, perform a caesarean section.

Symphysiotomy is not an option with failed forceps. 




  • Injury to facial nerves requires observation. This injury is usually self-limiting.

  • Lacerations of the face and scalp may occur. Clean and examine lacerations to determine if sutures are necessary.

  • Fractures of the face and skull require observation.


Uterine rupture may occur and requires immediate treatment.


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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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